Colin TyrieIndependent Drugs & Alcohol Advisor

From Medicine Shows to the ‘Silk Road’....

Prohibition, regulation, legalisation, drugs, medicines, tonics, snake oils and just getting high

Most of us shop on line, even for sex and relationships,so why not for drugs and medications?

…markets and promotions sell.

The ‘Genie’ is out of the (pill)

bottle’

The margin between legal and illegal is complex and often untested in law.

Ethylphenidate (EPH), a designer drug package, illustrating ‘loophole law’

EPH ‘crystal’….legal crack?

The development of a ‘super drug’

M-Cat and (the click of a)

mouse.....

When a popular brand is banned…

How information gets distorted.

Drugs can be seen as less marginalising than mental health problems

Nothing like a good headline

story....

…to keep the mundane facts from getting in the way

We can miscalculate the level of

consumer concern...

...and we can appear to be

tackling the problems...

….or even colluding or endorsing it.

Keeping a record of samples

Little available data so anecdotal information very useful.

Reports of mephedrone injecting from 2011/12, mostly Wales and N.E. England.

Evidence of mephedrone injecting in MSM groups through London Club Drug Clinic and ‘hidden’ clubbing populations.

Reports of IV use of other stimulants; mostly ethylphenidate (EPH) and methiopropriamine (MPA), but also ‘crystal’ methamphetamine (Tina), and ketamine (‘psychedelic heroin’).

Scottish police reported injection related harms from EPH (ACMD report on EPH), and very early reporting from Eire on injecting harms associated with mephedrone).

Injecting NPS; should we be worried?

Reporting from Eire and Scotland both involved people who had a long history of injecting heroin, this will have influenced their vascular health and IV practice e.g. use of acidifiers. Amphetamine injectors suffered less acute problems and what problems they experience are related to ‘frequency of IV use as opposed to the ‘drug’ itself.

Reports from ‘chem-sex’ groups appear to suggest the awareness of safer IV use is much greater although ‘risk’ behaviours are part of the attraction.

Reports from IV users of NPS are often from people who are over 40 yrs of age with associated likeliness of vascular deterioration.

IV NPS users will need more equipment…..we’re talking boxes of 100 x 1ml on every visit.

The ‘evidence’; ‘wheat from chaff’.

Slamming, bumping,

bare-back bell-ringing.

72 hour party people.

Chem-sex – a new phenomena?

Very difficult to obtain data but likelihood is this is not new but a widening acceptance of injecting combined with pushing of boundaries, may have driven a trend.

Shigella outbreaks increasing diagnosis rates in the UK by 750% with most of those infected gay men or MSM.

31% reported IV drug use (‘slamming’) and attending sex parties often organised spontaneously over mobile phone apps.

A significant number of these men were HIV+ and many had also acquired HCVduring this time period (2005-13)

Nam (National AIDS Monitor) 2014

The drugs

Mephedrone, drone, M-cat – Possibly the most well known new drug and

extremely popular for its similarity to ecstasy (MDMA) in empathic effect.

Crystal Methamphetamine, crystal, Tina – Crystal meth is one of the most

popular drugs in the US, South Africa, Australia and parts of Europe and

Africa. Rarely seen in the UK probably due to many factors but making an

appearance more frequently within hard-core gay/MSM clubs

GHB (Gammahydroxybutyrate) and GBL, liquid ecstacy, G – a popular drug

on the clubbing scene and in particular gay/MSM clubs. Disinhibiting and

euphoria enducing.

Ephylphenidate (EPH) – an analogue amphetamine and a by product of

methylphenidate (Ritalin and alcohol combined). A salt, EPH can be

slammed and will be almost indistinguishable from IV cocaine. Sold as part

of a blend in some ‘legal highs’ e.g. ‘Ching’.

Methiopropramine (MPA)– the audible affect experienced when a peak dose

of stimulant drug is reached believed to be on the edge of an overdose.

Ketamine and MXE– a dissociative analgesic, easily injected and popular in

parties. Associated risk of bladder atrophy and ulceration in regular users.

Poppers and Nitrous Oxygen– Both legal to possess and both have seen a

resurgence of interest.

Sildenafil/Viagra– arguably the most purchased medicine/drug on the

internet. Implications on cardio-vascular health and painful priapism

(erection that will not return to flacid state). Priapism is a medical emergency

and should not be left untreated. High risk reactions of both viagra and

poppers with some HIV medications.

Alcohol - not to be forgotten as the most common drug of choice and an

increased capacity for alcohol through stimulant drugs being used.

Terminology

Slamming – injecting drugs, usually stimulants and intravenously. Sometimes involves deliberate sharing of equipment and blood.

Rig – equipment used to inject but refers usually to syringe and needle only.

Bump – a line for insufflating (snorting).

Booty-bump – taking drugs by anal route (UYB – up your bum).

Chem sex parties – usually organised via internet and involving drugs and sex, often with high risks taken under the influence of stimulant drugs.

Bell-ringer – the audible affect experienced when a peak dose of stimulant drug is reached believed to be on the edge of an overdose.

Party-bottom – a man who accepts anal penetration submissively.

Sling – a harness worn by a ‘party bottom’ which enables ease of anal penetration by random party-goers.

Sero-sorting – HIV+ men seeking other HIV+ men for sex and slamming.

A busy weekend on NPS

A weekend of chem-sex

‘it’s okay, I’m only chipping’

Track marks

Three days later with no IV use

Fastest growing drug trend

Poorly researched

Like NPS, there are no long term studies

Like NPS, on line sales are the norm and legality is confusing

‘Roid rage’ is unlikely to be a direct effect of AAS use, more likely an individual behaviour observed on people who have used steroids or the abdication of responsibility (useful in legal defence)

Possibly a ‘functional drug’ for many who are employed in jobs where being muscular and defined in body shape is an advantage

Possible OCD and neurosis type behaviours, eating disorders and personality type disorders, but no usable data

Performance and Image Enhancing Drugs (PIEDs)

A synthetic replication of some of the characteristics of herbal cannabis.

A powder or granule of extremely high potency THC (tetrahydrocannabinoid) sprayed or dusted over benign vegetable matter to replicate the ‘feel’ of cannabis.

Some SCRAs are licensed for medical use e.g. nabilone and sativex.

The most popular NPS and also the least well understood.

Many reports of concern including mental health services, A&E, emergency services, prison services, schools, colleges, and more recently, coroners reports.

Media reports have been poorly researched and confusion over legality of certain SCRAs is widespread, including politicians and law enforcewment.

Synthetic Cannabinoid Receptor Agonists

‘SCRAface’ – the Spice Girl who turned bad!

Dependency syndrome experienced on an increasingly wider scale

No evidence based interventions or detoxification procedures available

Symptoms are often the opposite to those alleviated by herbvalcannabis e.g. nausea, muscle cramps, psychotic experiences – often unpleasant and prolonged

Dosages are incredibly difficult to weigh or ‘eyeball’

Toxicity screening is difficult and may be inaccurate

Appears to have become a drug of choice for heroin users in relapse, homeless people, young and drug naïve groups, people with mental health problems

Problems associated with SCRAs

Weak evidence base – unlikely to improve rapidly, leaving few options for treatment

People with mental health problems appear to be particularly vulnerable to both positive and negative experiences

Lack of clarity on legal status, harms and mandatory drug testing all inflame use of NPS indirectly but as a consequence

Drug ‘recovery model’ does not fit with NPS users but mental health recovery model may be more appropriate

Possible drug interventions e.g. serotonin syndrome

Psychological ‘fall-out’ for stimulant users and people engaged in risk behaviours e.g. injecting/slamming

Implications for Dual Diagnosis

Thank you for listening

colin.tryrie@icloud.com

www.mhsc.nhs.uk/legalhighs

07887 363 980